A Report on the Use of Telehealth in Otolaryngology: In the Pre COVID-19 Era
Introduction
Telehealth refers to a broad range of communication technologies that can be used to improve public health and enhance an individual’s care. The major components of telehealth include telemedicine, or the remote delivery of clinical services to patients, e-health, the use of electronic technology in support of health care services, surveillance, education and research, and m-health, the use of mobile devices to support the practice of health care. Historically, the use of telehealth in the fields of radiology, dermatology, and pathology has been extensive and clearly demonstrated efficacy.1 In comparison, traditional surgical training highlights the importance of the bedside interaction and physical examination. The importance of the surgeon’s hands guiding diagnosis and management is an underlying theme and central construct in surgical training and practice. Despite this, telehealth offers many potential advantages to surgical specialties.
Within the field of otolaryngology, Burgess et al.2 stated that the long-term care of chronic ear conditions as well as post-surgical care of tympanostomy tubes has been addressed by using telehealth. The same authors also reported the development of a remote speech therapy program using teleconferencing.2 These innovations included the use of a teleconferencing system as well as video-otoscopy, which can, in turn, promote education through the creation of a library of tympanic membrane images. Kokesh et al.3 found significant advantages in otolaryngologic health care delivery where telehealth technologies were incorporated into daily practice. In the remote setting of Anchorage, Alaska, timely subspecialty care was difficult. Significant delays were noted due to climate and the fact that patients living in rural Alaska had to fly to their provider for appointments. Adoption of a telehealth program, which included video-otoscopy, video laryngoscopy, as well as audiology consultation, was shown to facilitate timely diagnosis and treatment of patients in such settings.3,4 The authors also noted that their telehealth program enhanced positive relationships between otolaryngologists, audiologists, family practice physicians, and pediatricians.4 Urquhart et al. created a telehealth program to follow patients after parathyroid surgery. In this study, significant cost savings and decreased travel were noted for patients.5 Similarly, Rimmer et al. found that for non-acute outpatient otolaryngology follow-up visits, patients waited on average 10 min for telemedicine appointment times and saved an average commute time of 78 min. In particular, they found there was high utility for postoperative patient care via telemedicine, with 95% of patients reporting satisfaction with these visits.6
Despite positive outcomes noted in surgical subspecialties with the use of telehealth programs, challenges to implementing wider adoption remain. Consideration of the respective patient population and its electronic health literacy and accessibility to technology is important to create an ideal environment for telehealth, particularly in otolaryngology. This is especially true for head and neck surgical oncology patients who have had total laryngectomies, free-flap reconstruction, and glossectomies, which hinder their abilities to communicate via telehealth. In a study by Bailey et al., a survey was conducted comparing patient e-Health literacy in an academic otolaryngology clinic with that of a rural clinic, both in West Virginia.7 Results indicated a need for adequate resources, particularly in rural areas, to assist patients with knowledge and access to telehealth resources.7 From a provider standpoint, Saigi-Rubió et al. noted multiple barriers that prevented clinicians from adopting telehealth programs.8 They noted that only 50% of physicians thought that telehealth programs would improve quality and decrease cost. Ease of use significantly affected acceptance of technology into a system. Physicians had significant concerns about decreased productivity when adopting telehealth programs. Security concerns also affected physicians’ willingness to adopt telehealth into their daily practice.8
The degree of telehealth usage in otolaryngology at a national level as well as barriers to its implementation remain unclear. COVID-19 has had a tremendous worldwide impact in changing the utilization of telehealth Before a March 2020 Medicare waiver, the Centers for Medicare and Medicaid Services could only pay for telehealth when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. After this waiver, doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers could offer telehealth to their patients.
Greater national insights into the evolving usage of telehealth could help in developing strategies and policy for adoption of this highly relevant health care innovation into the field of otolaryngology. The primary goal of this study was to determine the proportion of practicing otolaryngologists who used some type of telehealth program in their daily practice before the COVID-19 pandemic, as well as factors that positively and negatively impacted the usage of telehealth.
Materials and Methods
Study Design
The University of Cincinnati Institutional Review Board approved this study as exempt. This was a cross-sectional study, which surveyed registered members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). All data were collected and managed at the University of Cincinnati by using Research Electronic Data Capture (REDCap), a secure Web-based software platform designed to support data capture for research studies.9,10 A link to a short REDCap survey was sent via e-mail by the AAO-HNS to the membership distribution list after approval of the survey by the academy.
Additional inclusion criteria required that the responding AAO-HNS member be registered as working within the United States and that the member complete the entire questionnaire associated with this study.
On March 27, 2019, all physician and physician-in-training members of AAO-HNS were emailed a questionnaire on the utilization of, and barriers to, the adoption of telehealth technology. Data were collected from those who responded by completing the questionnaire between March 27 and April 10, 2019.
The questionnaire used for assessing utilization and barriers to the adoption of telehealth was adapted from a previously reported questionnaire by Doarn et al.11 and was qualitatively modified for our study. The survey included several domains that focus on: (i) physician characteristics; (ii) practice characteristics; (iii) attitudes toward and barriers to using telehealth and its components, telemedicine, m-health, and e-Health; (iv) use of telehealth among telehealth users; and (v) beliefs about telehealth (Appendix A).
Statistical Analysis
Descriptive statistics, including frequencies and percentages, were calculated on all responses. In addition, responses regarding patient involvement in telemedicine and telehealth were examined by region of practice. The SAS version 9.4 (SAS Institute, Cary, NC) was used to conduct all analyses.
Results
In this cohort study, we utilized a survey tool to characterize the adoption of telehealth in AAO-HNS members as well as barriers to its usage. One hundred eighty-four responses were received from physician-in-training (N = 9, 5%) and practicing otolaryngologists. Their characteristics are summarized in Table 1. Of the respondents, 20% were female, 78% were Caucasian, 73% were >45 years of age, and 51% had been in practice for >20 years.
| NUMBER (N) | PERCENT (%) | |
|---|---|---|
| Gender | ||
| Male | 144 | 79.12 |
| Female | 37 | 20.33 |
| Other | 1 | 0.55 |
| Ethnic group | ||
| Hispanic | 4 | 2.23 |
| Non-Hispanic | 175 | 97.77 |
| Race | ||
| Caucasian | 141 | 77.9 |
| African American | 4 | 2.21 |
| Asian/Pacific | 18 | 9.94 |
| Native American | 0 | 0 |
| Decline | 13 | 7.18 |
| Other | 5 | 2.76 |
| Age | ||
| 18–25 | 0 | 0 |
| 26–35 | 15 | 8.24 |
| 36–45 | 35 | 19.23 |
| 46–55 | 56 | 30.77 |
| 56–65 | 50 | 27.47 |
| 66+ | 26 | 14.29 |
| Clinical role | ||
| Private practice | 93 | 51.38 |
| Academic practice | 64 | 35.36 |
| Physician-in-training | 9 | 4.97 |
| Other | 15 | 8.29 |
| Level of education | ||
| MD | 171 | 92.93 |
| DO | 8 | 4.35 |
| PhD | 1 | 0.54 |
| MBA | 0 | 0 |
| MHA | 1 | 0.54 |
| MPH | 0 | 0 |
| Other | 3 | 1.63 |
| Years of practice | ||
| Training | 9 | 4.89 |
| 1–5 | 21 | 11.41 |
| 6–10 | 14 | 7.61 |
| 11–15 | 19 | 10.33 |
| 16–20 | 28 | 15.22 |
| 21–30 | 58 | 31.52 |
| 31–40 | 35 | 19.02 |
We queried otolaryngologists about their familiarity with the broader concept of telehealth and its components; telemedicine, m-health, and e-Health. Most otolaryngologists indicated that they were familiar with telehealth, including its components and how it is used in practice; telehealth (52%), telemedicine (83%), e-Health (71.2%), and m-health (54%). Fifty percent of participants responded that they are currently using telehealth in their practice. However, some had heard the terms telehealth (42%), telemedicine (17%), e-Health (23.4%), and m-health (30%) but they were uncertain as to what they entailed. A few respondents had no knowledge of telehealth (6%), telemedicine (1%), e-Health (5.4%), and m-health (16%) (Fig. 1).
Fig. 1. Telehealth, telemedicine, e-Health, and m-health knowledgebase of participants.
Once broken down by AAO-HNS regions, the largest percentage of physicians using telemedicine and telehealth resided in the Mid-Atlantic (84%) and West Coast regions (67%), whereas the least percentage were located in the Great Lakes (36%) and Southwest regions (26%) (Fig. 2). Although most responses indicated that telehealth and its components were not applicable for practice (36%), some of the current uses in Otolaryngology include patient follow-up (27%), established patient (26%), new patient consult (23%), and post-surgery management (21%). (Fig. 3).
Fig. 2. Percentage of participants currently utilizing telehealth by the American Academy of Otolaryngology—Head and Neck Surgery region.
Fig. 3. Utility of telehealth in current practice.
Associations With use of Telehealth
Of all participants, 50% reported using some form of telehealth in their practice. We checked for associations between participant characteristics and use of telehealth. Of note, 70% of female physicians had been using telehealth in their practice compared with 45% of male physicians (p = 0.006). Although Caucasians were noted to be the majority of respondents to the survey, only 46% were reported to be utilizing telehealth in their practice compared with other ethnicities at 70% (p = 0.005). There was no difference between the use of telehealth for people <45 versus >45 years of age (p = 0.449). There was a difference in the use of telehealth in academic medicine (72%) compared with private practice (38%) (p < 0.0001). In addition, there was no statistical significance based on years in practice and use of telehealth (p = 0.364).
Barriers to Implementation of Telehealth
Regarding barriers to implementing telehealth, most otolaryngologists indicated reimbursement (65%), payment models (35%), quality of service (35%), and legal concerns (33%) as primary concerns (Fig. 4). Considering electronic medical record (EMR) and technology use, 53% were satisfied with their current use of EMR, 59% selected that EMR had not improved outcomes of patient care, 67% believed that typing was a hindrance to EMR utility, and 72% were comfortable utilizing smart devices for patient care. When comparing otolaryngologists who did and did not respond that EMR was a hindrance to their practice, there was no difference in years in practice or age (p = 0.763 and p = 0.247 respectively). In addition, years in practice and age did not have a significant role in affecting the comfort of using smart devices (p = 0.174 and p = 0.052, respectively).
Fig. 4. Reported barriers to telemedicine implementation by otolaryngologists.
Discussion
Telehealth is a major health care innovation that provides many benefits to the provision of patient care. In this study that took place before the COVID-19 pandemic, we sought to study the extent to which telehealth in otolaryngology was maturing into an accepted innovation by querying otolaryngologists about the use of telehealth in their practices as well as perceived barriers to its implementation. Half of the surveyed otolaryngologists were noted to be using some form of telehealth in their practice at the time of the study. We found that although most survey respondents were Caucasian male physicians >45 years of age and in practice for more than 20 years, the majority of respondents utilizing telehealth frequently (70%) were female otolaryngologists. The geographic areas in the United States with the highest telehealth utilization were the Mid-Atlantic and West Coast regions. Of the survey respondents who used telehealth, the primary usage was for some form of follow-up visit. During the study period, we found that the most important barrier reported to use telehealth reported was reimbursement from third-party payers. However, with the necessity for social distancing and increased utilization of telehealth during the COVID-19 pandemic, we are likely to see a drastic change when studying these barriers in future studies.
Physicians are clearly exposed to innovations and the ways in which advances in science and technology can improve patient care throughout their careers. In 1962, Everett Rogers popularized the diffusion of innovations theory, which points out that uncertainty and the potential to create a social change are underlying characteristics of an environment ripe for innovation.12 The adoption of innovation is a five-step process, which Rogers described as (i) exposure and developing an understanding of the innovation, (ii) developing an attitude or opinion regarding the innovation, (iii) deciding to accept or reject the innovation, (iv) beginning to implement it, and (v) confirming the decision. In many ways, telehealth is an example of diffusion of an innovation in the health care environment. The Health Information Technology for Economic and Clinical Health I Act of 2009 was established to accelerate the adoption of electronic health records and promote innovation in health care delivery by establishing financial incentives to practices and hospitals. Increasing quality in internet connectivity and widespread availability of smart devices has also greatly facilitated the adoption of telehealth.13
Telehealth technologies have been shown to improve patient access to care and potentially decrease the need for further in-person follow-up visits.14–16 The utilization of telehealth would afford those in rural settings the opportunity to follow up remotely without traveling long distances. Improved office efficiency and cost savings mostly related to patient travel expenses have also been cited as potential benefits of telehealth.15 Increased office efficiency stems from potentially shorter times for “e-visits” and the use of asynchronous e-visits. In one study utilizing this model of health care in a primary care setting, patient follow-up for chronic conditions after an initial office appointment was streamlined by using a Web-based questionnaire. The health care provider then evaluated the patient responses and provided feedback with regard to treatment decisions.17 Telehealth, in many ways, has the potential to completely redefine the role of primary care and specialty providers within the health care continuum.18
In our study, female otolaryngologists utilized telehealth more than their male counterparts. Age and years in practice did not have a statistical impact on the use of telehealth. In addition, telehealth was utilized more in the academic setting than in the private sector, likely secondary to barriers (e.g., reimbursement) more prominent for private practitioners. Due to the significant cost of implementing a telehealth system, academic practices may also have more flexibility than the private sector given their affiliations with larger health systems that may already be utilizing such a system. Finally, although we hypothesized that younger physicians might be more technologically savvy and therefore utilize telehealth more frequently, there were no data to support this assumption in this study.
Despite being exposed to and incentivized by innovation, some physicians remain reluctant to use telehealth technologies in their practice. Lack of reimbursement is a major obstacle for widespread implementation of telehealth and its components.1,13 Reimbursement models across the United States’ health care landscape are location specific and driven by regional law and policies, with guidelines most clearly delineated for rural areas. In general, the criteria for qualifying services are restrictive. For example, according to the Health Care Financing Administration at the time of the study, an appropriate telehealth consultation must be placed for a patient in an underserved rural area, require the presence of a licensed referring practitioner, exclude store-and-forward technology (except teleradiology), and obligate the consultant to remit 25% of the payment to the presenting practitioner.13 Certainly, complexities of reimbursement schedules and requirements for telemedicine have been a feature of the telehealth landscape, although changes in regulations may change significantly due to the COVID-19 pandemic.
Although barriers preventing physicians from adopting new telehealth technology exist, the actual technical aspects of using EMR are not often found to be challenging for physicians to grasp. In fact, many physicians have been shown to quickly master telehealth technology.19 However, infrastructure limitations may be more significant in limiting the adoption of telehealth care. Typically, high-speed internet access, technical support at the patient and provider locations, and secure data transmission must be in place for telehealth care.20 High-speed internet may be supplemented through cellular telehealth; however, high bandwidth is required for simultaneous audio and video at a quality that allows for patient interaction and clinical decision making.21–23 Lastly, unfamiliarity and inertia may lead to provider resistance. Telehealth is considered by some to be a novelty that does not function as an ordinary part of the health care system. Many physicians resist telehealth, because it adds an extra step to providing care; it is easier for them to continue providing care in the manner to which they have been accustomed. Despite this sentiment, numerous studies have demonstrated the accuracy in patient diagnosis and cost savings that are achieved with telehealth programs.24
Our results highlight the need for additional resources and education for otolaryngologists who are interested in implementing or have already begun to use telemedicine and telehealth more frequently, especially in the current COVID-19 era. In addition, the breakdown of responses from our survey allows for the potential to target specific implementation needs by the AAO-HNS region and analyze the potential barriers unique to these regions, including, but not limited to, legislation, Medicaid/Medicare reimbursement, the patient population need, and discussion of the potential utilization of telemedicine in training and credentialing. Above all, we believe that reworking and updating reimbursement models to include and encourage telehealth options will be critical to the widespread adoption of telehealth within our specialty.
Study Limitations
There are several limitations to this study. This is a cohort design that utilizes a national organization’s membership data. Data were collected by using a questionnaire. Individual responders (i.e., those who completed the questionnaire) may be more technology perceptive or prone to use telehealth in their practice. This design introduces undercoverage, nonresponse, and voluntary response bias into the study. This is not a random sampling of all otolaryngologists. However, pragmatic and financial limitations preclude a true random sampling. This study, nevertheless, may serve as a baseline for future studies, particularly in the comparison of telehealth usage during the study period (pre-COVID-19) and the current and post-COVID-19 era.
Conclusions
In this survey study of the United States’ otolaryngologists before COVID-19, we quantified telehealth implementation and identified barriers to usage. Half of the surveyed otolaryngologists used some form of telehealth at the time of the study. The most commonly cited obstacle to physician adoption of telehealth was reimbursement from third-party payers. Based on our results, education regarding effective implementation of telehealth should be prioritized. This is especially relevant as we witness a paradigm shift due to the COVID-19 pandemic era of social and physical distancing, resulting in increased utilization of telehealth. Future studies should assess the increase of telehealth utilization since COVID-19 and how it has affected the delivery of health care.
Acknowledgments
The authors acknowledge the AAO-HNS for approval of their questionnaire and its distribution to the AAO-HNS members. In addition, the authors would like to thank Sue Miller for her assistance with the RedCap database.
Disclosure Statement
The authors have no disclosures or conflicts of interest to report in the past 24 months.
Funding Information
No funding was received for this article.
References
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Appendix
Appendix A. Adoption of Telemedicine and Telehealth in Otolaryngology—What is the Barriers Questionnaire (Adapted from Doarn et al.11)
| 1. |
Gender: |
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□Male □Female □Other |
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| 2. |
Ethnic group: |
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□Hispanic □Non-Hispanic |
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| 3. |
Race: |
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□Caucasian □African American □Asian/Pacific Islander □Native American |
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□Decline to answer □Other |
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| 4. |
Age: |
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□18–25 □26–35 □36–45 □46–55 □56–65 □66 or over |
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| 5. |
Which best describes your clinical role? |
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□Private practice □Academic practice □Physician-in-training □Other |
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| 6. |
Current level of education (check all that apply): |
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□MD □DO □PHD □MBA □MHA □MPH □Other |
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| 7. |
Practice location—Enter Zip Code |
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| 7a. |
Estimate the population of your city: |
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□<25,000 □25,001–100,000 □100,001–250,000 □250,001–500,000 |
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□500,001–1,000,000 □>1,000,000 |
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| 8. |
Years of practice: |
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□Physician-in-training □1–5 □6–10 □11–15 □16–20 □21–30 □31–40 |
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| 9. |
Which terminology are you most knowledgeable about? |
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| I understand the definition and its use | I have heard the term, uncertain what it entails | No knowledge of these | |
|---|---|---|---|
| Telemedicine | |||
| Telehealth | |||
| e-Health (e.g., electronic health record, remote monitoring) | |||
| m-health (e.g., smartphone applications) |
| 10. |
Regarding question 9 above, are you currently using any of these in your clinical practice? |
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□Yes □No □Not sure |
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| 11. |
If you are using telemedicine, telehealth, e-Health, or m-health, how did you become aware of it? (check all that apply). |
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□From clinical practice |
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□Change in policy/administrative directive |
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□From an educational event (CME event, conference, lecture) |
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□From a journal article |
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□From a colleague |
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□From a patient |
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□Not Applicable |
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□Other |
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| 12. |
If you are using telemedicine, telehealth, e-Health, or m-health, which of the following are you using it in? (check all that apply) |
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□New patient consultation |
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□Established patient visit |
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□Postsurgical evaluation and management |
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□Second opinion |
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□Rehabilitation—audiology, speech or language, swallowing, other |
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□Cancer treatment follow-up |
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□Patient follow-up |
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□Education |
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□Not applicable |
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□Other |
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| 13. |
Of the list below, which of the following is a hindrance to the acceptance of telemedicine, telehealth, e-Health, and m-health to your practice? |
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□I don’t believe in telemedicine or mobile health for my patient care |
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□Legal issues |
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□Cross-state licensure |
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□Challenges with management |
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□Reimbursement for this approach |
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□Concerns over security and privacy of records and interactions over a telemedicine network |
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□Quality of service |
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□Fear of technology |
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□Change in workflow |
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□Patient satisfaction |
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□Payment models |
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□Limited capabilities |
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□Not applicable |
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| 14. |
Are there other barriers to telemedicine, telehealth, e-Health, and m-health? □Yes □No |
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| 15. |
How much do you agree or disagree with the following ideas? |
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| Strongly disagree | Disagree | Neutral | Agree | Strongly agree | No Opinion | |
|---|---|---|---|---|---|---|
| I think there should be required training in telemedicine, telehealth, e-Health, or m-health | ||||||
| I would like to see more information on credentialing of telemedicine, telehealth, e-Health, or m-health at my institution | ||||||
| The policy of my institution must change with respect to the integration of telemedicine, telehealth, e-Health, or m-health in clinical practice | ||||||
| More resource(s) should be made available regarding telemedicine, telehealth, e-Health, or m-health |
| 16. |
Please click Yes or No: |
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| I |
am satisfied with my current use of EMR, e-Health: □Yes □No |
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| I |
think the EMR has improved patient outcomes for the care that I provide: □Yes □No |
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Typing is a hindrance to using EMR: □Yes □No |
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| I |
am comfortable using smart devices for the delivery of patient care: □Yes □No |
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